Despite common recommendations and quasi universal health care coverage in all European countries, there are large differences in the utilisation patterns of different health services. Little comparative information is available on different types of health service utilisation and variations in utilisation patterns over a longer time span. The objective of this study is to compare and investigate individual and cross-country determinants of health care utilisation habits over the life span across European countries. We found that while there is a general shift toward more regular and preventive care utilisation in all countries; there are still signifi cant social inequalities between countries and cohorts. There is also evidence that once the individual effects have been isolated, cross-cohort and country differences in the prevalence of regular care use are partly associated with differences in welfare states interventions.

In order to improve financial access to complementary health insurance (CHI) in France, a CHI voucher program was introduced in 2005, called Aide Complémentaire Santé (ACS). ACS is intended for households whose resources are just above the free CHI plan eligibility threshold (CMU-C). Four years later, the program concerns only 18% of the eligible population.

We developed a controlled experiment with the National Health Insurance Fund in order to test whether this low take-up rate is due to the current financial aid being insufficient or whether it is explained by a lack of information on the application process. Three groups of eligible households living in an urban area in the north of France were randomly selected: a control group benefiting from the current financial aid, a group benefiting from a 75% voucher increase, and a last group benefiting from a 75% voucher increase and invitation to an information meeting on ACS.

Six months after experiment started, we observe a small but positive effect of the voucher increase on ACS take-up. Surprisingly, both treatments, the invitation to a briefing and the voucher increase, seem to cancel each other out. However, attending the briefing has a positive and significant impact on ACS take-up. Thus, this study confirms that ACS is complicated and hardly hits its target. Moreover, CHI beneficiaries and non-beneficiaries don’t respond differently to treatments, which suggests that the central issue of ACS low take-up rate is not the CHI cost itself but most certainly that of the access to information, the cost and the complexity of the application process.

Adverse selection, which is well described in the theoretical literature on insurance, remains relatively difficult to study empirically. The traditional approach, which focuses on the binary decision of “covered” or “not”, potentially misses the main effects because heterogeneity may be very high among the insured. In the French context, which is characterized by universal but incomplete public health insurance (PHI), we study the determinants of the decision to subscribe to supplemental health insurance (SHI) in addition to complementary health insurance (CHI). This work permits to analyze health insurance demand at the margin. Using a panelized dataset, we study the effects of both individual state of health, which is measured by age and previous individual health spending, and timing on the decision to subscribe. One striking result is the changing role of health risk over time, illustrating that adverse selection occurs immediately after the introduction of SHI. After the initial period, the effects of health risks (such as doctors’ previous health expenditures) diminish over time and financial risks (such as dental and optical expenses and income) remain significant. These results may highlight the inconsistent effects of health risks on the demand for insurance and the challenges of studying adverse selection.

Using the microsimulation model ARAMMIS, this study attempts to measure the impacts of introducing an out-of-pocket (OOP) maximum threshold, or a safety net threshold, on consumer copayments for health care financed by the abolition of the Long-term Illness Regime (ALD) in France. The analysis is based on a comparison of different safety net threshold rules and their redistributive effects on patients’ OOP payments.
We attach particular importance to indicators that bring to light changes in OOP payment levels and measure their impact on the equity of OOP distribution. The first section outlines the French National Health System to provide a better understanding of the stakes involved in reforming the health care reimbursement rules under the Compulsory Health Care Insurance scheme. In the second section, we describe the hypotheses retained, the database and the microsimulation model. The final section presents key findings, measuring the impact of the reform at both individual and system levels.

This paper proposes a method to quantify the contribution of inequalities of opportunities and inequalities due to differences in effort to be in good health to overall health inequality. It examines three alternative specifications of legitimate and illegitimate inequalities drawing on Roemer, Barry and Swift’s considerations of circumstances and effort. The issue at stake is how to treat the correlation between circumstances and effort. Using a representative French health survey undertaken in 2006 and partly designed for this purpose, and the natural decomposition of the variance, the contribution of circumstances to inequalities in self-assessed health only differs of a few percentage points according to the approach. The same applies for the contribution of effort which represents at most 8%, while circumstances can account for up to 46%. The remaining part is due to the impact of age and sex.

Using the microsimulation model ARAMMIS, this study attempts to measure the impacts of introducing an out-of-pocket (OOP) maximum threshold or a safety net threshold on consumer copayments for ambulatory care financed by the abolition of the Long-term Illness Regime (ALD) in France. The analysis is based on a comparison of different safety net threshold rules and their redistributive effect on patients’ OOP. We attach particular importance to indicators that bring to light changes in OOP payment levels and measure their impact on the equity of OOP distribution. The first section outlines the French National Health System to provide a better understanding of the stakes involved in reforming the healthcare reimbursement rules under the Compulsory Health Care Insurance scheme. In the second section, we describe the hypotheses retained, the data base and the microsimulation model. The final section presents key findings measuring the impact of the reform at both individual and system levels.

The development of so-called me-too drugs leads to controversial debates dealing with their substitutability, the opportunity of their presence on the market and their price. In this paper, we first bring together me-too drugs in 31 homogeneous groups of drugs considering that drugs in each group have to show the same principal molecular structural features and the same therapeutic indications. We then calculate in each group the price discrepancies between the first-in-class and each me-too drug in the class and we analyze explaining factors of these gaps. We consider the life cycle of each drug as a whole over the period between 2001 and 2009, considering both the date of the arrival on the market and later events such as price changes. We use a multi-level model which takes into account the temporal structure of the data and the fact that me-too drugs belong to a group.

Results show that in a group, me-too drugs are on average 59% more costly than firstin-class. In a given group, more innovation is associated with higher price gaps. On the contrary, arrival of generic drugs on the market or the fact that drugs are included in reference price groups (so-called “Tarif Forfaitaire de Responsabilité” [TFR] in France) tend to reduce the price gaps between me-too drugs and first-in-class. For those drugs that are available in several dosages, monotonic pricing, i.e. a price which is proportional to dosage, leads to higher price discrepancies and can be considered as unfair for patients who have to buy higher dosages. Finally, price gaps increase with drugs market shares, which contrasts with the price rule announced by the regulator.

Conventional health surveys focus on current health and social context but rarely address past experiences of hardship or exclusion. However, recent research shows how such experiences contribute to health status and social inequalities. In order to analyse in routine statistics the impact of lifelong adverse experiences (LAE) on various health indicators, a new set of questions on financial difficulties, housing difficulties due to financial hardship and isolation was introduced in the 2004 French National health, health care and insurance survey (ESPS 2004).
Logistic regressions were used to analyze associations between LAE, current socioeconomic status (SES) (education, occupation, income) and health (self-perceived health, activity limitation, chronic morbidity), on a sample of 4308 men and women aged 35 years and older.
In our population, LAE were reported by 1 person out of 5. Although more frequent in low SES groups, they concerned above 10% of the highest incomes. For both sexes, LAE are significantly linked to poor self-perceived health, diseases and activity limitations, even controlling for SES (OR>2) and even in the highest income group. This pattern remains significant for LAE experienced only during childhood.
The questions successfully identified in a conventional survey people exposed to health problems in relation to past experiences. LAE contribute to the social health gradient and explain variability within social groups. These questions will be useful to monitor health inequalities, for instance by further analyzing LAE related health determinants such as risk factors, exposition and care use.

Published in:European Journal of Public Health.
Contribution of Lifelong Adverse Experiences to Social Health Inequalities: Findings from a Population Survey in France.
Cambois E., Jusot F.

Effect of a French Experiment of Team Work between General Practitioners and Nurses on Efficacy and Cost of Type 2 Diabetes Patients CareMousquès J.*, Bourgueil Y.*, Le Fur P.*, Yilmaz E.**
Irdes working paper n° 29. 2010/01.

This study aims to assess the efficacy and the cost of a French team work experiment between nurses and GPs for the managing of type 2 diabetes patients. Our study was based on a case control study design in which we compare the evolution of process (standard follow-up procedures) and final outcomes (glycemic control), and the evolution of cost. The study is realized for two consecutive periods between type 2 diabetes patients followed within the team work experiment (intervention group) or by “standard” GPs (controlled group).

After 11 months of follow-up, we showed that patients in the intervention group, compared with those in the controlled group, have more chances to remain or to become: correctly followed-up (with OR comprise between 2.1 to 6.8, p<=5%) and under glycemic control (with OR comprise between 1.8 to 2.7, p<=5%). The latter result is obtained only when a visit for education and counselling has been delivered by a nurse in supplement to systematic electronic patient registry and electronic clinical GPs reminder. All these results are obtained without difference in costs between the intervention and the controlled groups.

Finally, this experimentation of team working can be considered both effective and efficient. Our findings may have implications in the design of future larger primary care team work experiments to be launched by French health authorities.

* Irdes, Prospère
** Drees (Health Ministry)

Published in: Health Policy, vol 98, n° 2-3, 2010/12, 131-143.
Effect of a French Experiment of Team Work between General Practitioners and Nurses on Efficacy and Cost of Type 2 Diabetes Patients Care.Mousquès J., Bourgueil Y., Le Fur P., Yilmaz E.